title: Factors associated with intensification of oral diabetes medications in primary care provider-patient dyads: a cohort study.
abstract: OBJECTIVE
  Although suboptimal glycemic control is known to be common in diabetic adults, few studies have evaluated factors at the level of the physician-patient encounter. Our objective was to identify novel visit-based factors associated with intensification of oral diabetes medications in diabetic adults.
  
  
  METHODS
  We conducted a nonconcurrent prospective cohort study of 121 patients with type 2 diabetes and hyperglycemia (A1C > or =8%) enrolled in an academically affiliated managed-care program. Over a 24-month interval (1999-2001), we identified 574 hyperglycemic visits. We measured treatment intensification and factors associated with intensification at each visit.
  
  
  RESULTS
  Provider-patient dyads intensified oral diabetes treatment in only 128 (22%) of 574 hyperglycemic visits. As expected, worse glycemia was an important predictor of intensification. Treatment was more likely to be intensified for patients with visits that were "routine" (odds ratio [OR] 2.55 [95% CI 1.49-4.38]), for patients taking two or more oral diabetes drugs (2.82 [1.74-4.56]), or for patients with longer intervals between visits (OR per 30 days 1.05 [1.00-1.10]). In contrast, patients with less recent A1C measurements (OR >30 days before the visit 0.53 [0.34-0.85]), patients with a higher number of prior visits (OR per prior visit 0.94 [0.88-1.00]), and African American patients (0.59 [0.35-1.00]) were less likely to have treatment intensified.
  
  
  CONCLUSIONS
  Failure to intensify oral diabetes treatment is common in diabetes care. Quality improvement measures in type 2 diabetes should focus on overcoming inertia, improving continuity of care, and reducing racial disparities.
authors.affiliation: Division of General Internal Medicine, Department of Medicine, Johns Hopkins University Schoolof Medicine, Baltimore, Maryland, USA. sgolden4@jhmi.edu
authors.forename: Shari Danielle
authors.initials: SD
authors.lastname: Bolen
authors.forename: Eric
authors.initials: E
authors.lastname: Bricker
authors.forename: T Alafia
authors.initials: TA
authors.lastname: Samuels
authors.forename: Hsin-Chieh
authors.initials: HC
authors.lastname: Yeh
authors.forename: Spyridon S
authors.initials: SS
authors.lastname: Marinopoulos
authors.forename: Maura
authors.initials: M
authors.lastname: McGuire
authors.forename: Marcela
authors.initials: M
authors.lastname: Abuid
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Brancati
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000375:Aging / Q000502:physiology / Q000523:psychology; D015331:Cohort Studies; D015897:Comorbidity; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000188:drug therapy*; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000188:drug therapy*; D007004:Hypoglycemic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D008329:Managed Care Programs; D008396:Maryland; D008875:Middle Aged; D010349:Patient Compliance; D011320:Primary Health Care; D044469:Racial Groups; D018401:Sample Size
chemical_list: D007004:Hypoglycemic Agents